Healthcare Provider Details

I. General information

NPI: 1861781601
Provider Name (Legal Business Name): VICTOR JOHN STATHIS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4994 JOE HOWARD STREET
MARIPOSA CA
95338
US

IV. Provider business mailing address

4994 JOE HOWARD STREET
MARIPOSA CA
95338
US

V. Phone/Fax

Practice location:
  • Phone: 209-742-5600
  • Fax: 209-742-7500
Mailing address:
  • Phone: 209-742-5600
  • Fax: 209-742-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH37612
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS012735
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: